Cancer of the Pancreas

To most of us, 16 July 2013 is going to be just another day. But for Madam Low, it is a day of heady excitement and grand anticipation – a day that she literally thought she would never see. I first met Madam Low, 53, in November 2011. She complained of her abdomen being bloated with gas and an upper abdominal pain that radiated to her mid-back.

She was investigated at another hospital and was suspected to have a cancer of the pancreas with metastatic spread to the liver.

A liver biopsy was carried out but the results were inconclusive. At that point, her family decided to see me for a second opinion. The clinical suspicion of metastatic cancer of the pancreas was high because the cancer marker called CA19-9 was markedly elevated at more than 100,000 units, when the normal is less than 37. I often see patients with modestly raised CA19-9.

This is a very sensitive but non-specific tumour marker. There are many non-malignant conditions that can cause this spike – including inflammatory conditions such as arthritis, bronchitis or even skin eczema. Instead of conducting a barrage of expensive and often inconclusive tests, I usually suggest monitoring the marker over time.

However, in this case, there was little doubt that Madam Low, a part-time sales promoter, had cancer. The clinical history, blood tests and radiological findings all pointed to it. A repeat CT-guided biopsy of the liver metastasis was carried out under direct imaging. The biopsy confirmed that Madam Low had an adenocarcinoma of the pancreas with spread to the liver.

There are several types of pancreatic cancer – adenocarcinoma being the most common, aggressive and often deadly. In patients with metastatic pancreatic cancer, the average life span is often quoted as three to six months. For a patient with stage four pancreatic cancer, the options are either to opt for best supportive care (BSC) or palliative chemotherapy.

Treatment with palliative chemotherapy has only modest success. Because of this, there are many doctors who would recommend BSC for these patients.

Furthermore, the chemotherapy is associated with side effects, risks of complications and high cost. This rather bleak picture was presented to Madam Low, and she had to exercise her personal choice. Each patient, presented with the same scenario, will take into consideration different factors in making their decision. Mrs Low was clear what she wanted: “I really want to make it for my second daughter’s graduation. I missed my elder daughter’s and I really regret it,” she said. Graduation Day: July 16, 2013.

With that sole consideration in mind, the patient and her family decided to embark on treatment. Even before the chemotherapy could start, she started vomiting after every meal. Further evaluation confirmed that the primary in the pancreas had increased in size resulting in blockage of the duodenum. The ingested food was stuck in the stomach, which could not empty.

To overcome the obstruction, a stent was placed in the duodenum to stretch open the lumen and allow food to pass through.

Weekly chemotherapy was started on 16 November 2011. With treatment, we have watched with trepidation and joy as the CA19-9 swung like a seesaw. We watched as the marker came down to as low at 4000, rising back to 80,000, and now coming back down to 50,000 units. As the markers came down, we documented a good response in both the pancreatic primary as well as in the liver metastases.

As the markers rose, the scans showed progression of her cancer. Through all the ups and downs, Madam Low has remained focused on the graduation day, which is coming up in next month. “What are we going to do after your daughter’s graduation?’ I asked her. “I don’t think about it. I am just thankful that I am going to make it,” she said. She recently told me what the doctors said to her when she was first suspected to have metastatic pancreatic cancer two years ago. “Very fast one, you.

What you want to eat, go and eat,” she was told. That was medical shorthand for “the end is nigh” as far as she was concerned. Still, although she knows that the end is not very far away, she also knows that she has come a long way. More importantly, she will get to mark an important milestone – on a date she thought would be well past her time.